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Massachusetts Residency
When you send us this form, please include a copy of the letter that we sent you asking for proof of your
Massachusetts residency status. The letter is called a “Request for Information.”
! I do not have a home address but intend to reside in Massachusetts. Mailing address:
Street ..................................................................................... City ................................................ State .......... ZIP ......................
I am not visiting Massachusetts for personal pleasure or to receive medical care in a setting other than a nursing home.
By signing below, I swear under the pains and penalties of perjury that everything on this form is true and complete
to the best of my knowledge. I know that if I lie on this form, my health coverage might end and I might have to repay
Call the Health Connector at (877) MA ENROLL, (877) 623-6765 or TTY: (877) 623-7773.
Questions?
Or call MassHealth at (800) 841-2900 or TTY: (800) 497-4648.
AFF-MR (10/19)